Measuring activity limitations in climbing stairs: development of a hierarchical scale for patients with lower-extremity disorders living at home

OBJECTIVE: To develop a hierarchical scale that measures activity limitations in climbing stairs in patients with lower-extremity disorders living at home.

DESIGN: Cross-sectional study with Mokken scale analysis of 15 dichotomous items.

SETTING: Outpatient clinics of secondary and tertiary care centers.

PARTICIPANTS: Patients (N=759; mean age +/- standard deviation, 59.8+/-15.0y; 48% men) living at home, with different lower-extremity disorders: stroke, poliomyelitis, osteoarthritis, amputation, complex regional pain syndrome type I, and diabetic foot problems.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: (1) Fit of the monotone homogeneity model, indicating whether items can be used for measuring patients; (2) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (3) intratest reliability, indicating repeatability of the sum score; and (4) differential item functioning, addressing the validity of comparisons between subgroups of patients.

RESULTS: There was (1) good fit of the monotone homogeneity model (coefficient H=.50) for all items for all patients, and for subgroups defined by age, gender, and diagnosis; (2) good fit of the double monotonicity model (coefficient H(T)=.58); (3) good intratest reliability (coefficient rho=.90); and (4) no differential item functioning with respect to age and gender, but differential item functioning for 4 items in amputees compared with nonamputees.

CONCLUSIONS: A hierarchical scale, with excellent scaling characteristics, has been developed for measuring activity limitations in climbing stairs in patients with lower-extremity disorders who live at home. However, measurements should be interpreted with caution when comparisons are made between patients with and without amputation.